Brockville General Hospital - Patient Survey

1. Patient Survey

Your views about our Patient Care Services are very important to us. Your experience will help us to improve existing services and influence our future plans.
Please take the time to complete our survey by rating the questions below. The survey should only take approximately 10 minutes. Note: once you start the survey you can not save it and return to it later.

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1. Please provide your contact information:
Or if you wish to remain anonymous, please only enter your postal code.

Please provide your contact information: Or if you wish to remain anonymous, please only enter your postal code. Name:
Address 1:
Address 2:
City/Town:
State/Province:
ZIP/Postal Code:
Email Address:
Phone Number:

2. Please rate each of the following questions:

	Poor	1	2	3	4	Excellent
Received all of the required information in advance of your visit	*Please rate each of the following questions: Received all of the required information in advance of your visit Poor	Received all of the required information in advance of your visit 1	Received all of the required information in advance of your visit 2	Received all of the required information in advance of your visit 3	Received all of the required information in advance of your visit 4	Received all of the required information in advance of your visit Excellent
Convenience of your appointment time (if applicable)	Convenience of your appointment time (if applicable) Poor	Convenience of your appointment time (if applicable) 1	Convenience of your appointment time (if applicable) 2	Convenience of your appointment time (if applicable) 3	Convenience of your appointment time (if applicable) 4	Convenience of your appointment time (if applicable) Excellent
Your privacy/confidentiality was respected at all times	Your privacy/confidentiality was respected at all times Poor	Your privacy/confidentiality was respected at all times 1	Your privacy/confidentiality was respected at all times 2	Your privacy/confidentiality was respected at all times 3	Your privacy/confidentiality was respected at all times 4	Your privacy/confidentiality was respected at all times Excellent
Comfort and pleasantness of patient area	Comfort and pleasantness of patient area Poor	Comfort and pleasantness of patient area 1	Comfort and pleasantness of patient area 2	Comfort and pleasantness of patient area 3	Comfort and pleasantness of patient area 4	Comfort and pleasantness of patient area Excellent
Courtesy and professionaliam of our staff	Courtesy and professionaliam of our staff Poor	Courtesy and professionaliam of our staff 1	Courtesy and professionaliam of our staff 2	Courtesy and professionaliam of our staff 3	Courtesy and professionaliam of our staff 4	Courtesy and professionaliam of our staff Excellent
Care provider introduced her/him self to you by name and occupation	Care provider introduced her/him self to you by name and occupation Poor	Care provider introduced her/him self to you by name and occupation 1	Care provider introduced her/him self to you by name and occupation 2	Care provider introduced her/him self to you by name and occupation 3	Care provider introduced her/him self to you by name and occupation 4	Care provider introduced her/him self to you by name and occupation Excellent
You were called by the name you prefer to be called by	You were called by the name you prefer to be called by Poor	You were called by the name you prefer to be called by 1	You were called by the name you prefer to be called by 2	You were called by the name you prefer to be called by 3	You were called by the name you prefer to be called by 4	You were called by the name you prefer to be called by Excellent
Explanation of any procedure(s) and education material(s)provided to you by nursing staff	Explanation of any procedure(s) and education material(s)provided to you by nursing staff Poor	Explanation of any procedure(s) and education material(s)provided to you by nursing staff 1	Explanation of any procedure(s) and education material(s)provided to you by nursing staff 2	Explanation of any procedure(s) and education material(s)provided to you by nursing staff 3	Explanation of any procedure(s) and education material(s)provided to you by nursing staff 4	Explanation of any procedure(s) and education material(s)provided to you by nursing staff Excellent
Explanation of any procedure(s) and education material(s) provided to you by Physician	Explanation of any procedure(s) and education material(s) provided to you by Physician Poor	Explanation of any procedure(s) and education material(s) provided to you by Physician 1	Explanation of any procedure(s) and education material(s) provided to you by Physician 2	Explanation of any procedure(s) and education material(s) provided to you by Physician 3	Explanation of any procedure(s) and education material(s) provided to you by Physician 4	Explanation of any procedure(s) and education material(s) provided to you by Physician Excellent
Efficient response to your inquiries or requests	Efficient response to your inquiries or requests Poor	Efficient response to your inquiries or requests 1	Efficient response to your inquiries or requests 2	Efficient response to your inquiries or requests 3	Efficient response to your inquiries or requests 4	Efficient response to your inquiries or requests Excellent
Cleanliness of your room and the hospital in general	Cleanliness of your room and the hospital in general Poor	Cleanliness of your room and the hospital in general 1	Cleanliness of your room and the hospital in general 2	Cleanliness of your room and the hospital in general 3	Cleanliness of your room and the hospital in general 4	Cleanliness of your room and the hospital in general Excellent
Quality and quantity of food and service delivery, if hospitalized	Quality and quantity of food and service delivery, if hospitalized Poor	Quality and quantity of food and service delivery, if hospitalized 1	Quality and quantity of food and service delivery, if hospitalized 2	Quality and quantity of food and service delivery, if hospitalized 3	Quality and quantity of food and service delivery, if hospitalized 4	Quality and quantity of food and service delivery, if hospitalized Excellent
Overall impression of the quality of care you received	Overall impression of the quality of care you received Poor	Overall impression of the quality of care you received 1	Overall impression of the quality of care you received 2	Overall impression of the quality of care you received 3	Overall impression of the quality of care you received 4	Overall impression of the quality of care you received Excellent
Ability to find your way in the hospital was easy	Ability to find your way in the hospital was easy Poor	Ability to find your way in the hospital was easy 1	Ability to find your way in the hospital was easy 2	Ability to find your way in the hospital was easy 3	Ability to find your way in the hospital was easy 4	Ability to find your way in the hospital was easy Excellent

3. Please indicate where you received services while in the hospital?
CCC- Charles St.Site
GSS- Garden St. Site

Please indicate where you received services while in the hospital? CCC- Charles St.Site GSS- Garden St. Site Complex Continuing Care(CCC)

Emergency

Day Surgery/Operating Room

Intensive Care (ICU)

Maternal/Child

Medical/Surgical Unit

Laboratory

Diagnostic Imaging(x-ray)

Palliative Care

Rehabilitation(GSS)

Other______________

4. Would you be willing to participate in a Patient Focus Group to represent the community in the future?

Would you be willing to participate in a Patient Focus Group to represent the community in the future? Yes

5. Please provide any additional comments.

Please provide any additional comments.

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